Delayed Emergency Response After Resident Fall with Head Injury
Penalty
Summary
A licensed vocational nurse (LVN) delayed contacting emergency services after a resident, who was on anticoagulant therapy and had a history of anoxic brain damage, diffuse traumatic brain injury, and epilepsy, experienced an unwitnessed fall and sustained a bump on the forehead. The LVN initially assessed the resident and, after consulting with the physician, was instructed to transfer the resident to an acute care hospital for evaluation. However, instead of immediately calling 911, the LVN first attempted to arrange transport through regular ambulance services, which both advised her to contact 911 due to the resident's use of blood thinners and the presence of a head injury. The delay in contacting 911 resulted in a late transfer of the resident, who was eventually transported to the hospital where a CT scan revealed a small right frontal subdural hematoma. Interviews with facility staff, including the Director of Nursing (DON), confirmed that the appropriate protocol in such cases would have been to contact 911 immediately, especially given the resident's anticoagulant use and head injury. The failure to promptly provide the necessary care and services as ordered and in accordance with the resident's needs constituted a deficiency in maintaining the resident's highest practicable well-being.